Provider Demographics
NPI:1316616287
Name:BEBRI, REGINALD
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:BEBRI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 PATRICIA PLACE DR
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3828
Mailing Address - Country:US
Mailing Address - Phone:734-776-6084
Mailing Address - Fax:
Practice Address - Street 1:1950 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5334
Practice Address - Country:US
Practice Address - Phone:269-321-0664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413720333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy